(i) Bowel management
Early and effective bowel management training is an important bowel rehabilitation tool for patients with neurogenic rectal dysfunction.
1. Objectives
(1) To enable the majority of patients to independently complete defecation on the toilet using gravity and natural defecation mechanism.
(2) To have the function of “social rhythm” to control defecation during the time of social activities.
2.The treatment of spinal shock period
(1) Loss of intestinal function during spinal shock, some patients may have paralytic intestinal obstruction, loss of bowel sounds, abdominal distension, such as food reflux may affect the diaphragm movement, tetraplegic patients may have respiratory difficulties. For such patients, care should be strengthened by performing gastrointestinal decompression, gastrointestinal nutrition and rehydration, and paying attention to local cleanliness and hygiene of the anus.
(2) Intramuscular injection of neostigmine, 0.3-0.5mg each time; or subcutaneous injection of ura choline, 2.5mg each time, once every 6 hours, can be used to help restore intestinal activity.
3.Defecation training
(1) Principles: Patients should be encouraged to start defecation training immediately after the acute period, following the following principles.
① Follow the pre-injury defecation habits as much as possible.
(ii) Avoid long-term use of laxatives, stool softeners can be used and the dosage is individualized.
③When problems occur, what causes should be identified.
④If the patient has a companion, try to schedule the training at a time when the patient has a companion.
⑤ if the patient does not have daily bowel movements, the patient should not be forced to do it every day
(6) Explain to the patient the problems related to defecation disorders, obtain the patient’s understanding and cooperation, and encourage the patient to actively participate in solving the problem.
(2) Training methods.
(①Behavior management: develop the habit of regular daily defecation, with the strongest gastrointestinal reflex after each morning.
② Defecation position: defecation position is better in squatting and sitting position, if you can’t squat and sit, it is better to use left side lying position.
③ muscle training: standing and walking can reduce constipation. The strength of the abdominal and pelvic muscles have a very important role in defecation movements, abdominal muscle training and inspiratory training should be carried out, such as sit-ups, deep abdominal breathing and anal lifting exercises.
(3) Defecation methods: Half an hour after meals, abdominal massage, or gentle finger massage around the anus to stimulate the defecation reflex. Regular stimulation to make the anal sphincter and pelvic floor muscle contraction can promote the formation of the central reflex of defecation. If the above methods are ineffective, use manipulation to remove stool, the operation should be gentle to avoid damage to the anal and rectal mucosa and anal sphincter.
4.Diet management
Should eat high fiber food, such as brown rice, whole grain food, vegetables, fruits, etc.; high volume and high nutrition food. Eat more peaches, prunes, cherries and other foods when constipated, and add tea, white rice, applesauce, etc. when having diarrhea. The right amount of water should be consumed daily, 2-2.3L per day is appropriate, excluding alcohol, coffee and diuretics.
(ii) Drug treatment
The aim of treatment against constipation is to soften stools, promote intestinal dynamics and stimulate defecation, rather than causing watery diarrhea. The following drugs can be used.
1.Volumetric laxatives
Also known as bulking agents, mainly for a variety of preparations rich in cellulose and Oxytetracycline, such as wheat bran, corn bran, konjac. Agar, methyl cellulose, psyllium preparations, etc..
2, osmotic laxatives
Oral salt osmotic laxatives, such as magnesium sulfate, sodium sulfate, etc. Excessive or repeated use of salt osmotic laxatives can cause hypermagnesemia, hypernatremia, etc. Sugar osmotic laxatives such as lactulose.
3.Stimulating laxatives
Also known as contact laxatives, the main effect is to stimulate intestinal peristalsis and promote defecation.
(1) anthraquinone plant laxatives, mainly in the large intestine, including rhubarb, senna, aloe vera, etc.. The rhubarb preparation can generally pass soft stools 4-8 hours after taking the drug. Senna can cause abdominal pain and pelvic organ congestion when stimulated too strongly, and is contraindicated during menstruation and pregnancy. Aloe preparations in the liver and gallbladder disorders should not be applied.
(2) Diphenhydramine: including phenolphthalein, oral intestinal decomposition can stimulate intestinal mucosal peristalsis and produce defecation. 4% of patients with long-term application of allergic reactions. Fruit guide tablets, a compound preparation of phenolphthalein. Long-term application may have an irritating effect on the kidneys, and animal tests have found the drug to have teratogenic effects. Castor oil. No laxative effect per se. By being decomposed by lipase in the small intestine, it releases stimulating ricinoleic acid, which causes increased intestinal peristalsis and promotes defecation. Rapid action, often accompanied by diarrhea, constipation after diarrhea, generally used to cleanse the intestines.
4.Lubricating laxatives
(1) liquid paraffin: can soften stool, suitable for avoiding forceful defecation.
(2) glycerin preparations: such as open cork can soften stool and anorectal stimulating effect, to promote defecation.
(3) Docusate sodium: short-term use is appropriate for patients with weak defecation.
(3) Electrical stimulation therapy: including external anal sphincter electrode placement to promote or inhibit defecation function.
(iv) Surgical treatment: nerve graft or colostomy or ileostomy.
(v) Acupuncture and herbal treatment.